Exhibit A-3-a - Vendor Certification Form.pdf

Form PUR 7801 (07/2024)

AHCA (10/24)

Page 1 of 3 Rule 60A-1.002, F.A.C.

Agency for Health Care Administration AHCA ITN 007-24/25, Exhibit A-3-a

Vendor Certification Form

I hereby certify the following on behalf of the vendor identified below:

Customer Indicator (Required, N/A, Determined by Vendor)

Vendor Indicator (Certified, N/A)

Certification

Required Certified Regardless of the dollar value of the goods or services provided, in accordance with the requirements of section 287.135(5), F.S., the vendor is not participating in a boycott of Israel and is not on the State Board of Administration’s “Quarterly List of Scrutinized Companies that Boycott Israel,” available at https://www.sbafla.com/governance/global-governance-mandates/

Required Certified If the goods or services to be provided are $1 million or more, in accordance with the requirements of section 287.135, F.S., the vendor is not on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Terrorism Sectors List (collectively, “Scrutinized List of Prohibited Companies”); does not have business operations in Cuba or Syria; and is not on the State Board of Administration’s “Scrutinized List of Prohibited Companies” available under the quarterly reports section at https://www.sbafla.com/reporting/

Required Certified The vendor is not on the Suspended Vendor List; it and its suppliers, subcontractors, or consultants to be utilized under the contract are not on the Convicted Vendor, Discriminatory Vendor, or Antitrust Violator Vendor Lists; and there is no pending or threatened action, proceeding, or investigation, or any other legal or financial condition, that would in any way prohibit, restrain, or diminish the vendor’s ability to satisfy the contract obligations.

The vendor is hereby informed of the provisions of sections 287.133(2)(a), 287.134(2)(a), and 287.137(2)(a), F.S., that identify the impacts to the vendor's ability or its affiliates’ ability to respond to the competitive solicitations of a public entity; to be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with a public entity; or to transact business with a public entity if it, or its affiliates, are placed on the Convicted Vendor, Discriminatory Vendor, or Antitrust Violator Vendor Lists of the Department of Management Services. The vendor is hereby further informed of the provisions of section 287.1351, F.S., that identify the impacts to the vendor’s ability to enter into or renew a contract with an agency, as defined in section 287.012, F.S., if it is placed on the Suspended Vendor List of the Department of Management Services.

https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.sbafla.com%2Fgovernance%2Fglobal-governance-mandates%2F&data=05%7C02%7CBrittany.Dambly%40dms.fl.gov%7C0adec150d13b4cc7ab2d08dcc60e9f98%7Ced173fed38394a3ca952140e906fed8d%7C0%7C0%7C638603013353010002%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=UT3gHJbzlUn95PDvOvb9ytmfLYPu%2Br6o%2FnBevfoq0MU%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.sbafla.com%2Freporting%2F&data=05%7C02%7CBrittany.Dambly%40dms.fl.gov%7C0adec150d13b4cc7ab2d08dcc60e9f98%7Ced173fed38394a3ca952140e906fed8d%7C0%7C0%7C638603013353015342%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=4o3wZFH%2B69KW8hJ2rUEAB3vbhSGolxhxlhPd0Bdzs2M%3D&reserved=0

Page 2 of 3 Rule 60A-1.002, F.A.C.

Required Certified If the contract grants the vendor access to an individual’s personal identifying information, the vendor is not prohibited from entering into the contract pursuant to section 287.138, F.S., and has completed the Form PUR 1355, “Foreign Country of Concern Attestation Form,” available at http://www.flrules.org/Gateway/reference.asp?No=Ref- 15843, and submitted it to the Agency.

N/A N/A If the vendor is a common carrier, as defined in section 908.111, F.S., or a contracted carrier, it is not prohibited from entering into the contract pursuant to section 908.111, F.S., and has completed the Form PUR 1808, “Common Carrier or Contracted Carrier Attestation Form,” available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14614, and submitted it to the Agency.

Required Certified The vendor is registered with, and uses, the E-Verify system for all newly hired employees in accordance with section 448.095, F.S.; and has not, within the last year, had a contract terminated under section 448.095(5)(c), F.S., by a public employer, contractor, or subcontractor, as defined by section 448.095(1), F.S.

Required Certified The vendor is in compliance with all applicable disclosure requirements set forth in section 286.101, F.S., and has not been deemed ineligible for a grant or contract funded by a state agency pursuant to section 286.101(7), F.S.

Required Certified If the contract is between a nongovernmental entity and a governmental entity, in accordance with section 787.06, F.S., the vendor has completed an affidavit signed by an officer or a representative of the vendor under penalty of perjury attesting that the vendor does not use coercion for labor or services as defined in section 787.06, F.S.

To fulfill this requirement, the vendor has completed Form PUR 2024, “Part A: Use of Coercion for Labor and Services,” and submitted it to the Agency.

N/A N/A If the Contract is for the provision of commodities, in accordance with section 287.1346, F.S., the vendor, and any entity under the control of vendor, has not been placed on the Forced Vendor List within the past 365 days or, if placed on the Forced Vendor List, has been removed pursuant to section 287.1346(5)(d), F.S.

If the Contract is for the provision of commodities, the Contractor will submit, prior to entering into or renewing the Contract, a written certification from senior management, as defined in section 287.1346(1)(c), F.S., which certifies to the best of their knowledge the commodities being offered pursuant to this solicitation have not been produced, in whole or in part, by forced labor.

To fulfill this requirement, the vendor has completed Form PUR 2024, “Part B: Provision of Commodities Produced by Forced Labor,” and submitted it to the Agency.

https://www.flrules.org/Gateway/reference.asp?No=Ref-15843 https://www.flrules.org/Gateway/reference.asp?No=Ref-15843 http://www.flrules.org/Gateway/reference.asp?No=Ref-14614 https://www.dms.myflorida.com/content/download/168924/file/pur%202024%20use%20of%20coercion%20forced%20labor%20combined%20final.docx https://www.dms.myflorida.com/content/download/168924/file/pur%202024%20use%20of%20coercion%20forced%20labor%20combined%20final.docx https://www.dms.myflorida.com/content/download/168924/file/pur%202024%20use%20of%20coercion%20forced%20labor%20combined%20final.docx https://www.dms.myflorida.com/content/download/168924/file/pur%202024%20use%20of%20coercion%20forced%20labor%20combined%20final.docx

Page 3 of 3 Rule 60A-1.002, F.A.C.

The vendor is hereby informed of the provisions of section 287.1346, F.S., that identify the impacts to a vendor’s ability to respond to the competitive solicitations of a state agency; to be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with a state agency; or to transact business for the provision of commodities with a state agency if it, or entities under the control of the vendor, is placed on the forced labor list in accordance with section 287.1346, F.S.

By signing below, I certify that I am authorized to complete and submit this Vendor Certification Form on behalf of the vendor.

Vendor Information Signatory

Company Name Signature Date

FEIN Typed or Printed Name

Title

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